Original Contribution

The relationship between paramedics’ level of education and degree of commitment^?

Melissa Alexander MS, Steven Weiss MD?, Darren Braude MD, Amy A. Ernst MD, Lynne Fullerton-Gleason PhD

Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131-0001, USA

Received 12 February 2008; revised 22 June 2008; accepted 29 June 2008

Abstract

Introduction: Emergency medical services (EMS) personnel attrition is a serious concern. Two fundamental psychological constructs linked to attrition are organizational and occupational commitment. Objective: To determine if there is a relationship between a paramedic’s degree of occupational/ organizational commitment and the following: (1) levels of education and (2) type of employment.

Methods: This was a cross-sectional study of paramedics in 6 states that require continued paramedic national registration. The data collection instrument consisted of demographic and occupational and organizational commitment sections. For level of education, the primary independent variable, each subject was placed into 1 of 3 groups: (1) certificate, (2) associate’s or bachelor’s degree in EMS (degree), and (3) paramedic certificate or degree with a non-EMS postbaccalaureate degree. Type of employment (fire based vs non-fire based) was also used as an independent variable. Organizational and occupational commitment was measured using validated scales for each. Analysis of variance was used for the comparisons between levels of each of the independent variables. A P b .05 was considered significant. Results: For occupational commitment, the participants with certificate level of education had a significantly higher score (88.9) than did those with either the degree (83.6) or postbaccalaureate (80.9) level of education. There were no significant differences for total organizational commitment. There were also no overall differences in occupational and organizational commitment between fire- and non-fire-based employees.

Conclusion: Paramedic occupational commitment shows a statistically significant decrease with increased level of education. Factors associated with commitment of more highly educated paramedics need to be explored.

(C) 2009

^? This project was supported by a grant from the National Association of Emergency Medical Technicians (NAEMT) and by information provided by the National Registry of Emergency Medical Technicians (NREMT). Publication and report contents are solely the responsibility of the authors and do not necessarily represent the official views of either NAEMT or NREMT.

* Corresponding author. Tel.: +1 505 272 5062; fax: +1 505 272 6503.

E-mail address: [email protected] (S. Weiss).

Introduction

In 2001, Taylor [1] discussed the threats to the health care safety net. Secondary to the 1986 EMTALA laws, the emergency medical services (EMS) system and emergency departments (EDs) became the primary source of the health care safety net while declining funding failed to support the shift in cost. The results for EMS were declining workforce

0735-6757/$ - see front matter (C) 2009 doi:10.1016/j.ajem.2008.06.039

and stressed EMS providers. Response times, diversion, and drop times at the hospital increased. With declining work- force, increasing stress on the workforce who remained, and no improvement in wages, the EMS system has been taxed by these changes. One study found that increasing call volume and urban work environment were both associated with a 3-fold increase in EMS job-related illnesses or injury [2]. Rates of EMS professionals leaving the profession are reaching record proportions, with some parts of the country having turnover rates as high as 20%, while the needs for EMS providers is expected to increase by 21% to 35% in the next few years [3]. This will continue to have a profound effect our nation’s safety net.

Emergency medical services personnel attrition has been cited as a serious concern [1,4,5]. Attrition is costly to organizations and can result in inadequate staffing levels and provision of services. Anecdotally, EMS job dissatisfaction has been attributed to relatively low pay, difficult working conditions, and lack of opportunities for career advancement. However, the body of EMS research in this area is limited and has not considered fundamental psychological constructs linked to attrition. Two of these constructs, organizational commitment and occupational commitment, have been well studied in the fields of psychology and management [1,6-13]. Organizational commitment refers to an individual’s psychological attachment to his/her organization, whereas occupational commitment refers to an individual’s psycho- logical bond to his/her occupation [6,10,11,13,14]. Ante- cedents of both organizational and occupational commitment include the level of investment that an individual has made to enter and remain in the occupation or organization, such as time, financial resources, and emotion [13]. Other ante- cedents include employees’ perceptions of how well they are regarded by organizational and occupational leaders and

perceptions of organizational justice [13].

One of the important investments made by EMS personnel, particularly by paramedics, is education. Emer- gency medical services education can be divided into 3 levels available to providers. A certificate level (certificate) represents the “traditional” education, an associate’s/bache- lor’s degree (EMS degree) represents a more “contemporary” education, and “postbaccalaureate” (post-bacc) includes all those with education beyond the bachelor’s degree level.

The primary purpose of this study was to determine if there isarelationshipbetweenaparamedic’sdegreeofoccupational/ organizational commitment and the following: (1) levels of education and (2) type of employment. The hypotheses were that (1) there is a relationship between paramedics’ levels of education and their degree of organizational commitment,

(2) there is a relationship between paramedics’ levels of education and their degree of occupational commitment, (3) there is a relationship between types of employment (fire based vs non-fire based) and paramedic’s degree of occupational commitment, and (4) there is a relationship between types of employment (fire based vs non-fire based) and paramedic’s degree of organizational commitment.

Methods

Study design

This study is a point estimation design of paramedic responses on demographic information compared with their responses on commitment scales. The data collection instrument and the study were approved by our institutional review board.

Study setting and population

The subject pool consisted of nationally registered paramedics from the 6 states in the United States that require biannual national re-registration as a requirement for state relicensure or recertification. These states were chosen because data collected from the Longitudinal Emergency Medical Technician Attribute and Demographic Study (LEADS) [15] showed evidence of overrepresentation of new paramedics in states where national registration is not required or where national registration is an initial licensure or certification requirement but is not required for relicensure or recertification.

Study design—data collection instrument

The data collection instrument consisted of demo- graphic, occupational commitment [14], and organizational commitment [11] sections. The demographic section requested information about age, sex, type of paramedic program, level of education, and number of years as an EMT and as a paramedic. The data collection instrument was mailed to the subjects.

Measurements—independent variables

The level of education reported by the subject was used as the independent variable. We divided the responses into the following 3 groups based on the levels of education available to EMS providers: (1) certificate level, (2) associate’s or bachelor’s degree (degree), (3) and beyond the bachelor’s degree level (post-bacc). An additional analysis was performed using the affiliation of the paramedic (fire based vs non-fire based).

Measurements—commitment scales

Commitment was the dependent variable. Both organiza- tional commitment and occupational commitment can be broken down into dimensions of affective, normative, and continuance commitment [11,16]. Affective commitment refers to the emotional attachment that an individual feels for his/her employer or occupation. Normative commitment refers to a feeling of obligation to one’s organization or occupation.

Continuance commitment refers to one’s perceptions of the perceived costs of leaving the organization or occupation [10,11]. Blau [14] argues for a fourth dimension of occupa- tional commitment in which the occupational continuance commitment is divided into accumulated costs and limited options. We used 3 levels of organizational commitment and 4 levels of occupational commitment as described.

Occupational commitment was measured using a validated scale with 24 items answered on a Likert scale of 1 to 6 [5]. The instrument contained 6 items each on normative and affective commitment, 8 items on continuance commitment-accumu- lated costs, and 4 items on continuance commitment-limited options. Results were summed to produce scores for each of the dimensions and then totaled for an overall occupational commitment score (24 questions; 24-144 total points).

Organizational commitment was measured using a validated scale that contains 18 items measured on a Likert scale of 1 to 6 [6,11]. There were 5 items each on normative and continuance commitment (4 items on limited options and 1 item on accumulated costs) and 8 items on affective commitment. Results were summed to produce dimension

Commitment Commitment type domain	No. of questions	Sample question
Occupational Affective	6	Being a paramedic
		is important to my
		self-image.
Occupational Normative	6	People trained in
		paramedicine have
		a responsibility to
		stay in it.
Occupational Continuance	8	I have too much time
accumulated		invested in EMS to
costs		change occupations.
Occupational Continuance	4	Given my
limited		background, I have
options		attractive alternative
		occupations.
Organizational Affective	5	I would be happy to
		spend the rest of my
		career with this
		organization.
Organizational Normative	7	I do not feel any
		obligation to stay
		with my current
		employer.
Organizational Continuance	1	If I had not put so
		much into this
		organization, I
		might consider
		leaving.
Each question is answered on a 1 to 6 scale indicating the degree to which the respondent agrees or disagrees with the statement (1 = strongly disagree to 6 = strongly agree).

scores and then totaled for an overall score for organization commitment (18 questions; 108 total points). Table 1 represents the 4 different types of occupational and 3 different types of organizational commitment. The number of questions and an example question are provided.

Statistics

A Power calculation was performed using a PASS 6.0 with a study design that uses an analysis of variance (ANOVA) with the 3 groups (certificate, degree, and post- bacc) and occupational and organizational commitment scores as the primary outcomes. Results were interpreted based on a post hoc least significant difference (LSD) test that takes into account multiple comparisons. Based on expert opinion, we chose an SD of 4.0 for the means, an SD of 20 for the data set, and an ? of .05. Using these values, the data would have a power of 80% to produce an effect size of

0.2 (small effect) with 82 participants in each of the 3 groups. We were thus willing to cease further attempts to enter subjects after we had reached 240 total participants.

Missing values were handled in 2 ways. When most of the questions on the commitment questionnaires were blank, the questionnaire was removed from the study. If 3 or fewer answers were missed in completing the questionnaires, the missing values were imputed as the median value for that particular question across all of the participants.

Table 1 Basic information about commitment scales used in the study

Data were analyzed using SPSS version 14. Bivariate Pearson correlations were calculated and a 1-way ANOVA was conducted to compare means on the organizational and occupational commitment scales and subscales based on the primary outcome variable of level of education. Post hoc significance was determined using a LSD test based on a significant result on ANOVA.

Results

There were 389 participants who returned data collection forms. Of the 387 respondents reporting sex, 72.1% (279) were male and 27.9% (108) were female. The mean +- SD age of the respondents was 39.9 +- 9.1 years. Also, 387 respondents reported their education levels. Seventy-two percent of the respondents were graduates of certificate paramedic programs, 22.5% were graduates of associate’s degree paramedic programs, and 5.4% were graduates of bachelor’s degree programs. Of those who reported a college major, 28% were in EMS. Three hundred eighty-four respondents reported the type of organization for their primary EMS employer. Fire- based services included 135 (35.2%) participants who worked for a transporting fire service and 9 (2.3%) who worked for a nontransporting fire service. Non-fire-based services included 88 participants (22.7%) who worked for private services, 32 (8.3%) who worked for a municipal service, 15 (3.9%) who worked for Air ambulance services, 54 (14.1%) who worked

Study data		LEADS interim [17]	LEADS final [15]
Average age (y)	39.94	35.1	33.3
No. of years as a paramedic	10.67	9.12
Male	72.1%	69%
Bachelor’s degree	27.3%	20.9%
Graduate degree	8.1%	6%
Employed by private sector	22.7%		32%

for hospital-based ambulance services, 12 (3.1%) who worked as a paramedic in a hospital department, and 41 (10.4%) who reported other types of employers.

Table 2 Comparison of study data with LEADS data

We compared our sample demographics with the LEADS data to assess similarity to a large known sample. Table 2 compares the key demographic characteristics of our sample with those reported in studies using LEADS data [15,17]. Our respondents were slightly older (39.94 years vs 35.1

Table 3 Occupational commitment results

Mean +- SD ANOVA Certificate vs degree Certificate vs post-bacc Degree vs post-bacc score P value comparisons comparisons comparisons

Mean difference Mean difference Mean difference (95% CI) (95% CI) (95% CI)

years for the LEADS interim report and 33.3 years for the LEADS final report) and had been paramedics slightly longer (10.67 vs 9.12 years). Our study group also had higher levels of education (27.3% vs 20.9% with bachelor’s degrees and 8.1% vs 6% with graduate degrees).

Of the 389 participants in the study, 12 (3%) were removed for having incomplete commitment scale scores, whereas 19 others had values for up to 3 variables imputed as described earlier. The total population analyzed was 377. The full range of values was represented by our study population.

Two participants did not complete the question about level of education and had to be excluded from the ANOVA analysis, leaving 375 participants for analysis of level of education vs commitment. There were significant negative correlations between level of education and occupational overall commitment (r = 0.14, P b .01) and occupational commitment-limited options (r = -0.23, P b.01). There were significant positive correlations between age and occupa- tional commitment, both affective (r = 0.14, P b .01) and normative (r = 0.13, P b .05).

Total occupational (maximum 144 points)		.01	+5.3 a (1.3 to 9.3)	+8.1 a (0.1 to 15.1)	2.8 (-5.0 to 9.6)
Certificate	88.9 +- 19.2
Degree	83.6 +- 18.3
Post-bacc	80.9 +- 13.1
Total	85.5 +- 18.5
Affective (maximum 36 points)		.15	+0.8 (-0.2 to 1.9)	-0.8 (-2.7 to 1.2)	1.6 (-3.5 to 0.3)
Certificate	29.6 +- 5.0
Degree	28.9 +- 4.7
Post-bacc	30.4 +- 5.7
Total	29.3 +- 4.9
Normative (maximum 36 points)		.53	+0.6 (-1.0 to 2.2)	-3.0 (-6.0 to 0.1)	-3.6 (-6.5 to -0.7)
Certificate	18.9 +- 7.6
Degree	18.4 +- 7.4
Post-bacc	22.1 +- 6.9
Total	19.0 +- 7.5
Accumulated costs (maximum 48 points)		b.01	+2.4 a (0.4 to 4.4)	7.1 a (3.4 to 10.8)	4.7 a (1.1 to 8.3)
Certificate	27.9 +- 9.7
Degree	25.6 +- 9.2
Post-bacc	20.8 +- 6.3
Total	26.1 +- 9.4
Limited options (maximum 24 points)		b.01	+1.4 a (0.4 to 2.4)	+4.8 a (3.0 to 6.6)	3.4 a (1.6 to 5.3)
Certificate	12.3 +- 4.8
Degree	10.9 +- 4.6
Post-bacc	7.5 +- 2.7
Total	11.2 +- 4.7
The study group included 375 paramedic respondents split such that their maximum education level was either certificate (n = 145), degree (associate’s or bachelor’s) (n = 201), or post-bacc (paramedic plus graduate-level education) (n = 29). Comparisons were made for the 3 education level groups. Post hoc significance was determined using an LSD test based on a significant result on ANOVA. CI indicates confidence interval. a The mean difference is significant based on a post hoc LSD test on ANOVA results that takes into account multiple comparisons.

Table 4 Organizational commitment results Mean +- SD score			ANOVA P value	Certificate vs degree comparisons Mean difference (95% CI)	Certificate vs post-bacc comparisons Mean difference (95% CI)	Degree vs post-bacc comparisons
						Mean difference (95% CI)
	Total organizational (maximum 108 points) Certificate Degree Post-bacc Total Affective (maximum 30 points) Certificate Degree Post-bacc Total Normative (maximum 48 points) Certificate Degree Post-bacc Total Continuance (maximum 30 points) Certificate Degree Post-bacc Total		.06	3.7 (0.6 to 6.8)	0.9 (-4.9 to 6.7)	-2.8 (-8.5 to 2.9)
		61.2 +- 15.1
		57.6 +- 14.4
		60.3 +- 13.5
		59.1 +- 14.7
			.03	+1.1 (-0.1 to 2.2)	-1.2 (-3.4 to 0.9)	-2.4 a (-4.5 to -0.3)
		18.8 +- 5.6
		17.6 +- 5.3
		20.0 +- 5.2
		18.2 +- 5.4
			.06	1.4 (-0.3 to 3.1)	-1.9 (-5.1 to 1.3)	-3.3 (-6.5 to -0.2)
		26.6 +- 8.4
		25.2 +- 7.9
		28.6 +- 7.2
		26.0 +- 8.1
			b.01	1.0 (0.1 to 2.0)	4.0 (2.2 to 5.9)	3.0 (1.2 to 4.8)
		15.8 +- 4.7
		14.8 +- 4.8
		11.8 +- 3.6
		15.0 +- 4.8
	The study group included 375 paramedic respondents split such that their maximum education level was either certificate (n = 145), degree (associate’s or bachelor’s) (n = 201), or post-bacc (paramedic plus graduate-level education) (n = 29). Comparisons were made for the 3 education level groups. Post hoc significance was determined using an LSD test based on a significant result on ANOVA. CI indicates confidence interval. a The mean difference is significant based on a post hoc LSD test on ANOVA results that takes into account multiple comparisons.

Table 3 shows the results for occupational commitment for the 375 participants included. An ANOVA indicated significant differences in total occupational commitment between certificate and both degree and post-bacc scores. The groups differed significantly in scores for both accumulated costs and limited options for continuance occupational commitment. There were significant differ- ences on 2 normative score comparisons, but they were not accepted because normative occupational commitment was not significant overall by ANOVA.

Table 4 shows the results for organizational commitment. Once again, 375 participants were entered into the analysis. The ANOVA indicated significant differences in the affective and continuance commitment subscores. When certificate was compared with degree education, there were significant differences in continuance and total organizational commit- ment score. When certificate was compared with post-bacc, there was a significant difference in continuance commit- ment. Comparing degree to post-bacc, there were significant differences in affective, normative, and continuance organi- zational scores.

All participants completed the question about service affiliation; therefore, 377 participants were analyzed in this section. Table 5 shows the results of the comparison of fire- and non-fire-based employees. Only the accumulated costs

subscore of occupational commitment and the continuance subscore of organizational commitment showed significant differences between the 2 groups.

Discussion

It is well known that EMS systems experience burnout and turnover. Retention strategies have been identified as a priority of EMS organizations [3]. More than 10 years ago, the Center for Health Professionals at the University of California, San Francisco discussed this issue of turnover among EMTs and paramedics in California. They attributed the high turnover rate in EMS to burnout, low compensation, lack of professional recognition, irregular work hours, and the boredom of providing routine transportation [18]. The 2007 Institute of Medicine report “EMS at the Crossroads” identifies a number of the key challenges to EMS personnel, which include recruitment and retention, workforce mobility, volunteerism, and burnout [19,20].

In this study, we chose commitment as a predictor variable to evaluate the effects seen among EMS providers throughout the United States. As far back as 1998, Lum and Kervin [21] have commented on the relationship between commitment and various aspects of nursing behavior. They noted previous

Fire based All others Mean 95% CI (n = 143) (n = 234) difference for difference

Occupational total 87.3 +- 17.5 84.4 +- 19.0 -3.7 -6.7 to 0.9 Affective subscore 29.0 +- 4.7 29.4 +- 5.1 0.4 -0.6 to 1.5 Normative subscore 19.3 +- 7.6 18.8 +- 7.4 -0.4 -2.0 to 1.1 Accumulated costs subgroup 27.5 +- 9.3 25.4 +- 9.4 -2.2 a -4.1 to -0.2 a Limited options subscore 11.7 +- 4.6 10.9 +- 4.9 -0.8 -1.8 to 0.2 Organizational total 58.5 +- 13.8 59.5 +- 15.1 1.0 -2.0 to 4.1 Affective subscore 17.6 +- 5.4 18.6 +- 5.4 1.0 -0.1 to 2.2 Normative subscore 25.2 +- 7.9 26.5 +- 8.1 1.4 -0.4 to 3.0 Continuance subscore 15.8 +- 4.9 14.5 +- 4.7 -1.0 a -2.3 to -0.3

a The mean difference is significant based on a post hoc LSD test on ANOVA results that takes into account multiple comparisons.

studies that had consistently shown that turnover, absentee- ism, and performance were strongly related to commitment. In addition, commitment had been related to a long list of other constructs such as Job satisfaction, job involvement, job tension, characteristics of employees’ job and role, and individual characteristics such as age, sex, need for achieve- ment, and tenure. The authors noted a high positive relation- ship between organizational commitment and turnover intentions. Using a cohort of nurses to evaluate a model including commitment, they found that organizational commitment had the strongest and most direct impact on intention to quit [21]. Somers et al [19] showed, using a 3- component commitment model (affective, normative, and continuance), that affective commitment emerged as the most consistent predictor of withdrawal intentions, turnover, and absenteeism. Correlation between commitment and turnover in these articles was as high as -0.56 (more commitment related to less turnover). No studies actually looked at the absolute change in commitment compared with turnover; however, graphs comparing commitment to “absenteeism” and to “intent to retain” suggest that an as little as 1/2 to 1 SD difference between groups in commitment scores led to significant differences in these outcome variables [19,21].

Table 5 Occupational and organizational commitment for the comparison of fire-based employees with all other types of EMS employees

Our study group was slightly older and more educated

than that of the LEADS study. The LEADS study did a stratified random sampling of all nationally registered emergency medical technicians (NREMTs) from the national registry, which included 114 361 basics and 44 365 paramedics. Of the 4835 participants in the sample, 698 basics and 1006 paramedics completed this study (35% response rate). The difference in our study sample was expected, as LEADS has reported an overrepresentation of younger respondents who have been in EMS for fewer years, because many states require national registration only for initial licensure or certification but not for renewal of licensure or certification. Fewer of our study participants were employed in the private sector, which could affect their results on organizational commitment. However, these results are comparisons of each individual’s results to

themselves and not an attempt at cross-sectional sampling. As such, the results would apply to any group of paramedics that are represented in our study population.

We found statistically significant negative correlations between paramedics’ levels of education and both dimensions of the continuance occupational commitment scale, as well as total occupational commitment. This indicates that higher levels of education are inversely related to occupational commitment. There was also a statistically significant negative correlation between continuance organizational commitment and level of education, indicating that higher levels of education among paramedics are associated with lower levels of organizational commitment. An interesting finding was that individuals with lower levels of education perceived that they had invested more in getting into and staying in their organization than did those who had actually invested in more education. One possible explanation is that those with higher education did not seek more education solely for occupational purposes but also for personal satisfaction, whereas those with certificate education may have sought paramedic training more for vocational than personal reasons.

As discussed earlier, turnover is among the consequences of lower organizational commitment [6,10,12,13]. Although the individual organizational and occupational commitment scores at which paramedics are likely to turnover are not yet known, higher levels of education lead to a greater number of employment opportunities, making it easier for employees who are dissatisfied to change employers or occupations. The correlations detected are small, but the relationships are worthy of consideration because of the current concern over EMS personnel attrition. It should not be assumed that employers’ financial outlays toward higher levels of paramedic education are poor investments. Instead, the importance of a more highly educated EMS workforce should be recognized, and efforts should be directed toward retention of highly educated paramedics. Studies have shown that there are mediators of organizational commitment, including perceptions of organizational justice and perceived organizational support [22]. It is important that employers

establish practices that increase employees’ perceptions of organizational justice and perceived organizational support. The EMS Agenda for the Future, published in 1996, envisions increased paramedic autonomy by the year 2009 as a means of reducing the burden of unnecessary Patient transport on the EMS system and EDs. According to this document, the paramedic of 2009 not only treats and transports patients with medical and traumatic emergencies but also provides patient education and referrals for social services and is able to discriminate between those patients who require immediate treatment and transport to the ED and those who require less acute care [23]. For EMS to play a role in meeting the current challenges to the health care system and to continue to grow as a profession, it is necessary to retain more highly educated paramedics within the occupa-

tion and within organizations.

Further studies assessing factors that increase paramedic commitment to the occupation and organization are encouraged. These studies should consider the effect of educational level because organizational and occupational factors increasing commitment may be different for those with higher levels of education. Factors of interest may include perceived levels and types of autonomy, responsi- bility, and intellectual challenge, in addition to the more commonly assumed factors of pay and work schedules. It is important to know where paramedics go when they leave EMS and what those occupations are offering that EMS is not. Such studies will be important in helping the occupation and employers retain more highly educated paramedics.

The monetary costs of attrition should not be the only concern of EMS organizations. Consequences of organiza- tional and occupational commitment include increased job satisfaction, increased job involvement, and organizational citizenship behavior (nonobligatory behaviors not related to formal rewards but important effective organizational opera- tion) [10,13,24]. These less tangible benefits of commitment are critical to growth and professionalism in EMS.

Limitations

This study is limited by the number of responses returned. Because it is not a randomly selected group, we cannot ensure that results from a different sampling of EMS personnel would not have led to different results. We are, however, only comparing each individual’s data to them- selves. We have made the assumption that, as long as we have the entire spectrum of possible commitment scores, the results reflect on the relationship between level of education, service type and degree of commitment.

In addition, the scales have not been standardized so we do not know how the commitment scores for EMS professionals may compare to those in other fields. All of our scales were in the range of 50% to 70% of the maximum possible commitment score for their scales. We do not know how this relates to other non-EMS occupations.

Although we found a significant relationship between our commitment constructs and turnover, we did not look at attrition directly. This would have required a very different study design. Although there is ample evidence of a correlation between the two, the results of this study should be evaluated cautiously so as not to induce a direct relationship to turnover or attrition. Also, we did not look at different levels of EMTs and did not break down our results by age group.

Many paramedics do not apply for relicensure through the national registry because their state does not require it. This may lead to some selection bias among those states that require their paramedics to relicense. We therefore cannot ensure the external validity of our results to this group of paramedics.

Conclusion

Based on statistically significant differences, occupational commitment and continuance organizational commitment among paramedics are lower as level of education increases. There is little relationship between type of employment and occupational or organizational commitment. Factors asso- ciated with commitment of more highly educated paramedics need to be explored.

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